Dentistry Section
DOI: 10.7860/JCDR/2015/12821.5856
Original Article
Anaesthetic Efficacy of 4% Articaine Mandibular Buccal Infiltration Compared To 2% Lignocaine Inferior Alveolar Nerve Block in Children with Irreversible Pulpitis
Veena Arali1, Mytri P2
ABSTRACT Background: Lidocaine is the gold standard anaesthetic solution that has been used since its inception into dentistry till date. Around 80% of failures have been reported when lignocaine has been used for inferior alveolar nerve block in children and adults with irreversible pulpitis. There is a need to use newer drugs which are available which have been reported to be effective like lignocaine, such as articaine. Although articaine has been used in adults, literature supporting its use in children is sparse. Aim: The purpose of this study is to compare the anaesthetic efficacy of 4% articaine buccal infiltration and 2% lignocaine inferior alveolar nerve block in children with irreversible pulpitis. It also aims to assess the need for supplemental intrapulpal injections.
Materials and Methods: This study was designed as a randomized double-blind cross over trial comparing the anaesthetic effectiveness of 4% articaine with 1:100,000 epinephrine in buccal infiltration and 2% lignocaine IAN block anaesthesia. The study subject and the pediatric dentist performing the pulpectomy procedures were blinded to the study. A sample size of 40 subjects in the age group of 5-8 y was included in the study. Results: The onset of anaesthesia with 4% articaine was faster as compared to 2% lignocaine. The duration of anaesthesia with articaine infiltration was shorter. The need for supplemental injection in the articaine group was less. Conclusion: Four percent articaine infiltration can be used in children with irreversible pulpitis. It can be used to replace the IAN block in children thereby reducing the post anaesthetic complications like lip biting.
Keywords: Articaine, Buccal infilteration, Irreversible pulpitis, Supplemental injection
Introduction Pain control in dentistry is an important part in reducing the fear and anxiety associated with dental procedures especially in children. Local anaesthetics form the back bone of pain control in dentistry and there has been a substantial research for a safe and effective anaesthetic agent for a few decades for endodontic procedures [1]. Two percent lignocaine is the gold standard and considered the most efficacious anaesthetic agent for use in pediatric and adult patients and has been widely used for inferior alveolar nerve blocks [2]. Clinical studies have shown the failure of IAN blocks to be approximately 44-84% and 0-36% in maxillary infiltrations which necessitated the need for supplemental injections in the form of intrapulpal, buccal infiltrations etc [3-5]. Articaine entered into the clinical practice in 1976 and has been widely used since then due to its enhanced efficacy and safety. Along with the ester group, articaine consists of thiophene ring instead of benzene ring which makes it different from other anaesthetic solutions. The increased diffusion of the articaine solution is attributed to the presence of thiophene ring, which increases the lipid solubility thereby allowing the solution to cross the lipid membrane [6]. According to some authors [7,8] due to the increased diffusion it can produce profuse pulpal as well as palatal anaesthesia after maxillary buccal infiltrations thus enabling the clinicians to avoid painful nerve block specially in children. The available literature indicates that articaine is equally effective when statistically compared to other local anaesthetics [9-15]. Many studies have shown articaine and lignocaine to be equally efficacious when used for providing IAN block, intraligamentary or Journal of Clinical and Diagnostic Research. 2015 Apr, Vol-9(4): ZC65-ZC67
infilteration techniques in irreversible pulpitis [11]. However, most of these studies are performed in adults and data about the efficacy in children with irreversible pulpitis are relatively sparse. Hence, the present study was done to evaluate the efficacy of 4% articaine buccal infiltration as compared to 2%lignocaine IAN block in children with irreversible pulpitis.
Materials and methods This study was designed as a randomized double-blind cross over trial comparing the anaesthetic effectiveness of 4% articaine with 1:100,000 epinephrine in buccal infiltration and 2% lignocaine 1:100,000 epinephrine IAN block anaesthesia. The study was conducted in Krishnadevaraya College of Dental Sciences, Bangalore in 2012-13. The study was in accordance with the ethical standards of the institutional ethical committee on human experimentation and with the Helsinki Declaration. The study subject and the paediatric dentist performing the pulpectomy procedures were blinded to the study. A sample size of 40 subjects in the age group of 5-8 y was included in the study. The following are the inclusion and exclusion criteria of the subjects in the study:
Inclusion criteria Deep dentinal caries irt 74,75,84,85. Moderate to severe spontaneous pain, positive response to electric pulp tester. Widened periodontal ligament space Children falling in the frankel behaviour rating scale of positive 65
Veena Arali and Mytri P, Articaine Infiltration in Irreversible Pulpitis
Exclusion criteria Allergies to local anaesthetics or sulphites H/O significant medical conditions Any medications Presence of abscess, sinus opening. Method: After obtaining the informed consent from the parents, 40 subjects were randomly divided into two groups. Group 1 constituted the 4% articaine group, while Group 2, 2% lignocaine group. The procedure was performed by 2 investigators. The procedure to be performed was explained to the patients. The investigator 1 administering all anaesthetics had no involvement in measuring outcomes. Randomization was performed by investigator 1 who delivered the local anaesthetic. Blinding of both the investigators was maintained until completion of the trial. All the interventions were performed in a dental hospital clinical setting. The following treatments were given at separate visits: 1. 1.8 ml 4% articaine with 1:100,000 epinephrine was used for buccal infiltration. The solution was injected in the mucobuccal fold adjacent to a mandibular first primary molar on the right side.
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Results Twenty subjects under the age of 5-8 y were treated with articaine and twenty subjects with lidocaine. Onset of anaesthesia: The mean time of onset of anaesthetic effect with articaine was found to be 50 sec while with lignocaine it was found to be 60 seconds which was found to be statistically non-significant (p > 0.85) [Table/Fig-2].
[Table/Fig-2]: Onset of anesthesia
[Table/Fig-3]: Duration of anesthesia
2. 1.8 ml 2% lignocaine with 1:100,000 epinephrine was used for IAN block. The solution was was injected on the left side. The treatment was performed by investigator 2 over a period of 2 visits which were separated by atleast one week interval. The same mandibular primary molar area was anaesthetized at each visit; the investigator 2 evaluated the onset of anaesthesia, pain during the procedure and the duration of anaesthesia. Behavior modified pain scale was used to assess the behavior of the child during the injection procedure.
Behavioral modified pain scale (TADDIO et al.,) [16] •
Facial display(eyebrow bulge/eye squeeze)
•
Arm/leg movements
•
Torso movements
•
Crying.
The investigator 2 assessed the pain present in the child during the access opening procedure. If the child did not allow the investigator to perform the procedure, the need for supplemental intra-pulpal injection was also assessed. Efficacy was determined on a gross scale immediately following the procedure by having both the subject and investigator rate the pain experienced by the subject during the procedure using a visual analog scale (VAS) [17-19]. The 10 cm VAS scale ranged from “it didn’t hurt” (smiley face = 0) to “worst hurt imaginable” (frowning face = 10) [Table/Fig-1]. The parent or guardian explained the method of marking the scale to the child. This assured the investigators that the child understood what he/she is supposed to do. A 10 cm scale similar to the one given to the child before the start of the procedure was given to the child to indicate the presence / absence of pain during the procedure. Duration of the anaesthesia was assessed after 1h and 24h after the procedure by a telephonic conversation. All the values obtained were tabulated and subjected to statistical analysis. Onset of anaesthesia and duration was analysed using Chi-square test and Mann-Whitney-Wilcoxon test were used for pain scores (p
DOI: 10.7860/JCDR/2015/12821.5856
Original Article
Anaesthetic Efficacy of 4% Articaine Mandibular Buccal Infiltration Compared To 2% Lignocaine Inferior Alveolar Nerve Block in Children with Irreversible Pulpitis
Veena Arali1, Mytri P2
ABSTRACT Background: Lidocaine is the gold standard anaesthetic solution that has been used since its inception into dentistry till date. Around 80% of failures have been reported when lignocaine has been used for inferior alveolar nerve block in children and adults with irreversible pulpitis. There is a need to use newer drugs which are available which have been reported to be effective like lignocaine, such as articaine. Although articaine has been used in adults, literature supporting its use in children is sparse. Aim: The purpose of this study is to compare the anaesthetic efficacy of 4% articaine buccal infiltration and 2% lignocaine inferior alveolar nerve block in children with irreversible pulpitis. It also aims to assess the need for supplemental intrapulpal injections.
Materials and Methods: This study was designed as a randomized double-blind cross over trial comparing the anaesthetic effectiveness of 4% articaine with 1:100,000 epinephrine in buccal infiltration and 2% lignocaine IAN block anaesthesia. The study subject and the pediatric dentist performing the pulpectomy procedures were blinded to the study. A sample size of 40 subjects in the age group of 5-8 y was included in the study. Results: The onset of anaesthesia with 4% articaine was faster as compared to 2% lignocaine. The duration of anaesthesia with articaine infiltration was shorter. The need for supplemental injection in the articaine group was less. Conclusion: Four percent articaine infiltration can be used in children with irreversible pulpitis. It can be used to replace the IAN block in children thereby reducing the post anaesthetic complications like lip biting.
Keywords: Articaine, Buccal infilteration, Irreversible pulpitis, Supplemental injection
Introduction Pain control in dentistry is an important part in reducing the fear and anxiety associated with dental procedures especially in children. Local anaesthetics form the back bone of pain control in dentistry and there has been a substantial research for a safe and effective anaesthetic agent for a few decades for endodontic procedures [1]. Two percent lignocaine is the gold standard and considered the most efficacious anaesthetic agent for use in pediatric and adult patients and has been widely used for inferior alveolar nerve blocks [2]. Clinical studies have shown the failure of IAN blocks to be approximately 44-84% and 0-36% in maxillary infiltrations which necessitated the need for supplemental injections in the form of intrapulpal, buccal infiltrations etc [3-5]. Articaine entered into the clinical practice in 1976 and has been widely used since then due to its enhanced efficacy and safety. Along with the ester group, articaine consists of thiophene ring instead of benzene ring which makes it different from other anaesthetic solutions. The increased diffusion of the articaine solution is attributed to the presence of thiophene ring, which increases the lipid solubility thereby allowing the solution to cross the lipid membrane [6]. According to some authors [7,8] due to the increased diffusion it can produce profuse pulpal as well as palatal anaesthesia after maxillary buccal infiltrations thus enabling the clinicians to avoid painful nerve block specially in children. The available literature indicates that articaine is equally effective when statistically compared to other local anaesthetics [9-15]. Many studies have shown articaine and lignocaine to be equally efficacious when used for providing IAN block, intraligamentary or Journal of Clinical and Diagnostic Research. 2015 Apr, Vol-9(4): ZC65-ZC67
infilteration techniques in irreversible pulpitis [11]. However, most of these studies are performed in adults and data about the efficacy in children with irreversible pulpitis are relatively sparse. Hence, the present study was done to evaluate the efficacy of 4% articaine buccal infiltration as compared to 2%lignocaine IAN block in children with irreversible pulpitis.
Materials and methods This study was designed as a randomized double-blind cross over trial comparing the anaesthetic effectiveness of 4% articaine with 1:100,000 epinephrine in buccal infiltration and 2% lignocaine 1:100,000 epinephrine IAN block anaesthesia. The study was conducted in Krishnadevaraya College of Dental Sciences, Bangalore in 2012-13. The study was in accordance with the ethical standards of the institutional ethical committee on human experimentation and with the Helsinki Declaration. The study subject and the paediatric dentist performing the pulpectomy procedures were blinded to the study. A sample size of 40 subjects in the age group of 5-8 y was included in the study. The following are the inclusion and exclusion criteria of the subjects in the study:
Inclusion criteria Deep dentinal caries irt 74,75,84,85. Moderate to severe spontaneous pain, positive response to electric pulp tester. Widened periodontal ligament space Children falling in the frankel behaviour rating scale of positive 65
Veena Arali and Mytri P, Articaine Infiltration in Irreversible Pulpitis
Exclusion criteria Allergies to local anaesthetics or sulphites H/O significant medical conditions Any medications Presence of abscess, sinus opening. Method: After obtaining the informed consent from the parents, 40 subjects were randomly divided into two groups. Group 1 constituted the 4% articaine group, while Group 2, 2% lignocaine group. The procedure was performed by 2 investigators. The procedure to be performed was explained to the patients. The investigator 1 administering all anaesthetics had no involvement in measuring outcomes. Randomization was performed by investigator 1 who delivered the local anaesthetic. Blinding of both the investigators was maintained until completion of the trial. All the interventions were performed in a dental hospital clinical setting. The following treatments were given at separate visits: 1. 1.8 ml 4% articaine with 1:100,000 epinephrine was used for buccal infiltration. The solution was injected in the mucobuccal fold adjacent to a mandibular first primary molar on the right side.
www.jcdr.net
Results Twenty subjects under the age of 5-8 y were treated with articaine and twenty subjects with lidocaine. Onset of anaesthesia: The mean time of onset of anaesthetic effect with articaine was found to be 50 sec while with lignocaine it was found to be 60 seconds which was found to be statistically non-significant (p > 0.85) [Table/Fig-2].
[Table/Fig-2]: Onset of anesthesia
[Table/Fig-3]: Duration of anesthesia
2. 1.8 ml 2% lignocaine with 1:100,000 epinephrine was used for IAN block. The solution was was injected on the left side. The treatment was performed by investigator 2 over a period of 2 visits which were separated by atleast one week interval. The same mandibular primary molar area was anaesthetized at each visit; the investigator 2 evaluated the onset of anaesthesia, pain during the procedure and the duration of anaesthesia. Behavior modified pain scale was used to assess the behavior of the child during the injection procedure.
Behavioral modified pain scale (TADDIO et al.,) [16] •
Facial display(eyebrow bulge/eye squeeze)
•
Arm/leg movements
•
Torso movements
•
Crying.
The investigator 2 assessed the pain present in the child during the access opening procedure. If the child did not allow the investigator to perform the procedure, the need for supplemental intra-pulpal injection was also assessed. Efficacy was determined on a gross scale immediately following the procedure by having both the subject and investigator rate the pain experienced by the subject during the procedure using a visual analog scale (VAS) [17-19]. The 10 cm VAS scale ranged from “it didn’t hurt” (smiley face = 0) to “worst hurt imaginable” (frowning face = 10) [Table/Fig-1]. The parent or guardian explained the method of marking the scale to the child. This assured the investigators that the child understood what he/she is supposed to do. A 10 cm scale similar to the one given to the child before the start of the procedure was given to the child to indicate the presence / absence of pain during the procedure. Duration of the anaesthesia was assessed after 1h and 24h after the procedure by a telephonic conversation. All the values obtained were tabulated and subjected to statistical analysis. Onset of anaesthesia and duration was analysed using Chi-square test and Mann-Whitney-Wilcoxon test were used for pain scores (p
